Health inspection·September 21, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 09/19/25, R3's record review of undated care plan documents an admission date of 10/06/2023 with diagnosis Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbance, Presence of Other Specified Functional Implants, REM Sleep Behavior Disorder, Visual Hallucinations, Dementia, Unspecified Severity, with Agitation, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, History of Falling, Acute Kidney Failure, and Major Depressive Disorder. The same care plan documents: R3 is at risk for fall related to weakness and needs assist with mobility. History of falls. Date Initiated: 10/09/2023 Revision on: 01/10/2025. R3 will reduce his risk of injuries from falls by the next review date. Date Initiated: 10/07/2023 Revision on: 07/31/2025 Target Date: 11/27/2025. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 10/09/2023. Encourage resident to be in common area during mealtimes Date Initiated: 05/15/2024. Encourage resident to lay down when visibly tired Date Initiated: 03/24/2025. Ensure all supplies are within reach when providing cares Date Initiated: 02/14/2025. Environmental rounding to ensure resident is positioned in the middle of the bed. Date Initiated: 03/11/2025. R3 has stated verbally R3 prefers to sit/lay on the floor directly, and at times will move himself to the floor. Date Initiated: 05/21/2024 Revision on: 05/21/2024. Offer alternate seating when patient is visibly tired or restless Date Initiated: 09/04/2025. Offer resident fluids and snack after early a.m. get up Date Initiated: 06/24/2024. Offer to adjust positioning of chair when resident visibly tired as he allows Date Initiated: 01/10/2025. Place floor mat on the floor next to bed. Date Initiated: 10/13/2023 Revision on: 10/24/2023 Place snacks in easily accessible area Date Initiated: 03/31/2025On 09/19/25, R3's record review of Minimum Data Set completed on 9/2/25 documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates R3 is cognitively intact.On 09/19/25, R3's record review of progress note dated 9/6/2025 at 06:14am documents V9 was on hall three middle way and turned to push the medication cart and observed R3 crawling in the hallway to the common area fully clothed with one slipper sock on.On 09/19/25, R3's record review documents a progress note entered by V3 Director of Nursing, dated 9/8/2025 at 10:09am stating that the Interdisciplinary Team (IDT) met to discuss the fall. Root cause: resident purposefully placed self on floor to crawl. Intervention: resident care planned to crawl on floor. when desired.On 09/21/25 at 11:30am, V1 Administrator, confirmed R3's care plan had not been revised/updated with new intervention. Event ID: Facility ID: 145732 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Normal 509 North Adelaide Normal, IL 61761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate resident centered interventions to prevent falls for one resident (R1) of three residents reviewed for falls in a sample list of four residents. This failure resulted in R1 falling from the wheelchair.Findings Include:Fall Policy dated 10/2024 documents that the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. The same policy also documents Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. Nursing personnel will be informed of residents who are at risk of falling. The fall risk interventions will be identified on the care plan.On 09/19/25, R1's record review of undated care plan documents an admission date of 08/15/25 with diagnosis Fracture of Left Calcaneus, Type 1 Diabetes Mellitus with Other Skin Ulcer, Fracture of Shaft of Right Tibia, Closed Fracture with Nonunion, and Muscle Wasting and Atrophy. The same care plan documents: R1 is at risk for falls related to the right shoulder Date Initiated: 08/16/2025 Revision on: 08/18/2025. R1 will have decreased risk of falls by next review date. Date Initiated: 08/16/2025 Revision on: 09/10/2025 Target Date: 11/27/2025. Anticipate and meet the resident's needs. Date Initiated: 08/18/2025. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 08/18/2025. Environmental rounds to ensure resident is in the middle of the bed to help prevent accidental exits from bed. Date Initiated: 08/17/2025. Sent to Emergency Department (ED) Date Initiated: 08/15/2025.On 09/19/25, R1's record review of Minimum Data Set (MDS) completed on 9/15/25 documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R1 is cognitively intact. The same MDS documents R1 is dependent on a total body mechanical lift for transfers.On 09/19/25, R1's record review of progress note dated 9/12/2025 at 6:35am V9 Nurse, documented R1 sustained a fall on 09/12/2025 5:15AM. Documents the incident occurred outside on driveway and R1, who is alert and oriented to time, person, place and situation, attempted to pull straps of the total body mechanical lift sling out from her front right wheel and slipped off the wheelchair.On 09/19/25, R1's record review of progress note dated 9/12/2025 at 09:59am, V3 Director of Nursing, documents the Interdisciplinary Team (IDT) met to discuss the fall. R1 was outside waiting for van to take R1 to dialysis. R1 called the west desk at approximately 05:15am and asked this writer for help removing the straps of lift sling from R1's wheels of R1's power wheelchair. The same progress note documents the root cause: resident slipped out of the chair pulling the lift sling out from under her. Intervention: educate resident regarding asking for assistance with sling placement. This intervention was not documented as completed.On 09/19/25, R1's record review of Comprehensive Incident Fall assessment dated [DATE] at 06:13am completed by V9 documents under section C number four (4) lists new interventions initiated immediately to prevent further falls. Documents to tuck straps of sling under resident. This intervention was not transcribed to the care plan.On 9/19/25 at 12:26pm, R1 stated on 09/12/25 R1 was rolling in R1's power wheelchair outside to wait on the van to take R1 to dialysis when the strap of the total body lift sling became tangled into the front wheel of the wheelchair and pulled the lift sling forward pulling R1's body forward. When R1 leaned forward R1 slid forward from the wheelchair to the ground. R1 further stated the seat belt on the wheelchair is broken and unable to be fastened. R1 stated R1 is unsure of the date the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145732 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Normal 509 North Adelaide Normal, IL 61761 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete seatbelt broke but was it broke after admission to the facility. R1 stated nursing staff are aware the seat belt is broken. On 9/19/25 at 12:59pm, V9 stated R1 called V9 from R1's cell phone indicating R1 needed help with the straps of the lift sling as they were caught under the wheel of the wheelchair. V9 stated V9 delivered the coffee V9 had and then proceeded outside to R1's location and R1 was sitting on the ground. V9 stated R1 stated R1 fell from the wheelchair due to the straps of the sling being under the wheels of the power chair. V9 stated R1 was assessed and gotten off the ground and returned to the wheelchair and the straps were then tucked under R1 to prevent further incidents. V9 stated R1 should be care planned to have the straps of the lift sling tucked under R1 to prevent further incidents.On 09/21/2025 at 08:54am, V4 Maintenance Director, stated V4 was unaware of the broken seatbelt on R1's wheelchair. V4 stated staff use the TELS computer program (maintenance request platform) to request service/repair orders for equipment needing repair.On 09/21/2025 at 09:43am, R1 stated that R1 wears the seatbelt at all times when R1 is in the wheelchair and had the seatbelt been working it would have been worn and R1 would not have fallen from the wheelchair.On 09/21/2025 at 11:03am, V1 Administrator, confirmed R1 fell from the wheelchair on 09/12/25 and the care plan did not have proper interventions to prevent a fall from the wheelchair. On 09/21/2025 at 11:33am, V11 (R1s Family), confirmed the seatbelt on R1's wheelchair was functioning upon admission and broke during R1's stay. V11 confirmed R1 wears the seatbelt to prevent falls from the wheelchair. Event ID: Facility ID: 145732 If continuation sheet Page 4 of 4